New concerns about antipsychotics for children

Various prescription medications are pictured in a file photo. Appearing in the latest issue of the Canadian Journal of Psychiatry, the study is raising fresh concerns around the escalating and widespread "off-label" use of antipsychotics in children.Photo by
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Children as young as preschoolers are being prescribed powerful antipsychotics for behavioural problems despite little to no evidence the drugs work in children of normal intelligence, Canadian researchers are warning.

Doctors from the University of Calgary and University of Toronto who searched medical literature for randomized trials testing so-called second generation antipsychotics, or SGAs, against placebos for the treatment of "disruptive behaviour" in children found that only one drug - risperi-done - appears to be effective when used in the short term, and at low doses.

But the researchers found only weak evidence that any of the drugs work in children with average IQs, the very children most frequently treated with antipsychotics.

Appearing in the latest issue of the Canadian Journal of Psychiatry, the study is raising fresh concerns around the escalating and widespread "off-label" use of antipsychotics in children.

Only one of the drugs - aripiprazole - has been officially approved in Canada for use in children under 18, and only then for the treatment of schizophrenia in youth aged 15 to 17.

Once reserved for psychosis and mania in adults, the drugs are being increasingly prescribed to children for attention-deficit/hyperactivity disorder, "conduct disorder" and "oppositional defiant disorder."

The pills can cause rapid and dramatic weight gain, as well as an increase in blood pressure, blood fats and other metabolic abnormalities, as well as neurological side effects such as problems moving.

Children especially appear to be more vulnerable to the side effects compared with adults, doctors say.

"The evidence regarding the efficacy of SGAs for disruptive behaviour in youth, especially in those with average IQs, is highly incongruous with pediatric prescribing patterns for these agents in North America during the past two decades," the authors write.

American prescription rates for the drugs doubled in preschoolers aged two to five from 1999 to 2007.

In Canada, the number of times a doctor recommended an antipsychotic drug for a child or teen increased by 114 per cent from 2005 to 2009. Ninety-five per cent of the recommendations were for an SGA.

For their study, the researchers found a total of eight studies, including four large trials involving risp-eridone, as well as a single study involving 19 teens treated with quetiapine. (Risp-eridone is the antipsychotic most frequently prescribed to children and adolescents, followed by quetiapine.)

Most were short studies, lasting an average of six weeks.

They found a decrease in aggressive behaviour in children treated with risperidone, but only "weak evidence at best that quetiapine makes a difference," said neurologist and lead author Dr. Tamara Pringsheim, an assistant professor at the University of Calgary.

Overall, most of the studies involved children who had borderline or sub-average IQ, she said.

Only one study that involved children with normal IQ found little difference between risperidone and placebo in reducing aggression.

"I suspect that many of the children who are receiving the drugs in Canada are not in this low IQ group," Pring-sheim.

"I struggle with this - if it works in children who have low intelligence then it makes sense that it may work as well in children of normal intelligence. I have no reason to think it shouldn't work.

"But it's most appropriate to have strong evidence in the group that you're primarily treating. We have only one very weak study in children of normal intelligence. We need to do more research so that we can feel more certain about the results."

She said the growing use of antipsychotics in children reflects a wider societal problem and failure of the health system. The drugs have become a convenient and relatively inexpensive way to deal with an aggressive child who needs intense psychosocial care.

"If you have a very aggressive child you can try to calm things, settle things with these medications," Pring-sheim said.

"But the most lasting and durable change is going to come from a behavioural or psychosocial program. Children need to learn these things and we just don't have the resources available in our communities to provide this to families."

Private programs can cost $150 an hour or more.

"No physician writes one of these prescriptions without careful consideration. No parent puts their child on an antipsychotic unless the situation is severe," Pringsheim added.

But, "families are struggling, and there's this perception of a lack of alternatives - 'I don't know what else I can do to help my child. Life is so hard right now, I have to do something.' "

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